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1.
Ideggyogy Sz ; 73(7-08): 269-273, 2020 Jul 30.
Artigo em Húngaro | MEDLINE | ID: mdl-32750244

RESUMO

A 21 year female polytraumatized patient was admitted to our unit after a serious motorbike accident. We carried out CT imaging, which confirmed the fracture of the C-II vertebra and compression of spinal cord. Futhermore, the diagnostic investigations detected the compound and comminuted fracture of the left humerus and femur; the sacrum and the pubic bones were broken as well. After the stabilization of the cervical vertebra, a tracheotomy and the fixation of her limbs were performed. She spent 1.5 years in our unit. Meanwhile we tried to fix all the medical problems related to tetraplegia and respiratory insufficiency. As part of this process she underwent an electrophysiological examination in Uppsala (Sweden) and a diaphragm pacemaker was implanted. Our main goal was to reach the fully available quality of life. It is worth making this case familiar in a wider range of public as it could be an excellent example for the close collaboration of medical and non-medical fields.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Diafragma/diagnóstico por imagem , Quadriplegia/reabilitação , Insuficiência Respiratória/terapia , Traumatismos da Medula Espinal/reabilitação , Traumatismos da Medula Espinal/terapia , Tomografia Computadorizada por Raios X/métodos , Cuidados Críticos , Feminino , Humanos , Quadriplegia/etiologia , Quadriplegia/fisiopatologia , Qualidade de Vida , Traumatismos da Medula Espinal/fisiopatologia , Traqueotomia , Resultado do Tratamento , Adulto Jovem
2.
J Trauma Acute Care Surg ; 89(1): 96-102, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32282755

RESUMO

BACKGROUND: Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. METHODS: We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. RESULTS: A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. CONCLUSION: To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. LEVEL OF EVIDENCE: Diagnostic tests or criteria, Level III.


Assuntos
Diafragma/diagnóstico por imagem , Fraturas das Costelas/complicações , Ultrassonografia/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Testes de Função Respiratória , Centros de Traumatologia
3.
Ann R Coll Surg Engl ; 102(6): e130-e132, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32326737

RESUMO

Minimally invasive oesophagectomy has become popular, but studies showed a higher rate of postoperative hiatus hernia compared with open oesophagectomy. Our video presents the laparoscopic biosynthetic mesh repair of a symptomatic giant hiatus hernia in a 71-year-old man who had undergone minimally invasive oesophagectomy one year earlier for distal adenocarcinoma of the oesophagus. The operative time was 120 minutes. The patient started oral intake on postoperative day one and was discharged on postoperative day three. Postoperative computed tomography at six months showed no signs of recurrence. In the setting of a symptomatic hiatus hernia post-minimally invasive oesophagectomy, we suggest an initial laparoscopic approach, because of its countless advantages.


Assuntos
Esofagectomia/efeitos adversos , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Complicações Pós-Operatórias/cirurgia , Toracoscopia/efeitos adversos , Adenocarcinoma/terapia , Idoso , Quimiorradioterapia Adjuvante , Colo Transverso/diagnóstico por imagem , Diafragma/diagnóstico por imagem , Diafragma/cirurgia , Neoplasias Esofágicas/terapia , Hérnia Hiatal/diagnóstico , Hérnia Hiatal/etiologia , Herniorrafia/instrumentação , Humanos , Intestino Delgado/diagnóstico por imagem , Laparoscopia/instrumentação , Masculino , Terapia Neoadjuvante , Readmissão do Paciente , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Telas Cirúrgicas , Técnicas de Sutura , Tomografia Computadorizada por Raios X , Resultado do Tratamento
4.
Can Assoc Radiol J ; 71(3): 313-321, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32157897

RESUMO

Traumatic diaphragmatic injury (TDI) is an underdiagnosed condition that has recently increased in prevalence due to its association with automobile collisions. The initial injury is often obscured by concurrent thoracic and abdominal injuries. Traumatic diaphragmatic injury itself is rarely lethal at initial presentation, however associated injuries and complications of untreated TDI such as herniation and strangulation of abdominal viscera have serious clinical consequences. There are 2 primary mechanisms of TDIs: penetrating TDI which tend to be smaller, more difficult to detect, and result in fewer complications; and blunt TDIs which are larger and have higher overall mortality due to associated injuries or delayed complications. The anatomy of thoracic and abdominal cavities distinguishes the epidemiology, pathophysiology, symptoms, treatment, and prognosis of right versus left TDI. Although there is no definitive radiologic sign for diagnosing TDI, many signs have been introduced in the literature and the concurrent presence of multiple signs increases the sensitivity of TDI detection. Conservative versus surgical management depends on mechanism of TDI, side, and most importantly the associated injuries.


Assuntos
Diafragma/diagnóstico por imagem , Diafragma/lesões , Hérnia Diafragmática Traumática/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Acidentes de Trânsito , Autopsia , Meios de Contraste , Diagnóstico Diferencial , Diafragma/cirurgia , Hérnia Diafragmática Traumática/cirurgia , Humanos , Imageamento Tridimensional , Escala de Gravidade do Ferimento , Traumatismo Múltiplo/diagnóstico por imagem
5.
PLoS One ; 15(3): e0229972, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32163474

RESUMO

OBJECTIVES: Bedside ultrasound techniques have the unique ability to produce instantaneous, dynamic images, and have demonstrated widespread utility in both emergency and critical care settings. The aim of this article is to introduce a novel application of this imaging modality by utilizing an ultrasound based mathematical model to assess respiratory function. With validation, the proposed models have the potential to predict pulmonary function in patients who cannot adequately participate in standard spirometric techniques (inability to form tight seal with mouthpiece, etc.). METHODS: Ultrasound was used to measure diaphragm thickness (Tdi) in a small population of healthy, adult males at various points of the respiratory cycle. Each measurement corresponded to a generated negative inspiratory force (NIF), determined by a handheld meter. The data was analyzed using mixed models to produce two representative mathematical models. RESULTS: Two mathematical models represented the relationship between Tdi and NIFmax, or maximum inspiratory pressure (MIP), both of which were statistically significant with p-values <0.005: 1. log(NIF) = -1.32+4.02×log(Tdi); and 2. NIF = -8.19+(2.55 × Tdi)+(1.79×(Tdi2)). CONCLUSIONS: With validation, these models intend to provide a method of estimating MIP, by way of diaphragm ultrasound measurements, thereby allowing evaluation of respiratory function in patients who may be unable to reliably participate in standard spirometric tests.


Assuntos
Diafragma/diagnóstico por imagem , Processamento de Imagem Assistida por Computador/métodos , Pressões Respiratórias Máximas/métodos , Modelos Biológicos , Adulto , Diafragma/fisiologia , Feminino , Voluntários Saudáveis , Humanos , Masculino , Pessoa de Meia-Idade , Ultrassonografia/métodos
6.
Anesthesiology ; 132(6): 1494-1502, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32205549

RESUMO

BACKGROUND: Management of acute respiratory failure by noninvasive ventilation is often associated with asynchronies, like autotriggering or delayed cycling, incurred by leaks from the interface. These events are likely to impair patient's tolerance and to compromise noninvasive ventilation. The development of methods for easy detection and monitoring of asynchronies is therefore necessary. The authors describe two new methods to detect patient-ventilator asynchronies, based on ultrasound analysis of diaphragm excursion or thickening combined with airway pressure. The authors tested these methods in a diagnostic accuracy study. METHODS: Fifteen healthy subjects were placed under noninvasive ventilation and subjected to artificially induced leaks in order to generate the main asynchronies (autotriggering or delayed cycling) at event-appropriate times of the respiratory cycle. Asynchronies were identified and characterized by conjoint assessment of ultrasound records and airway pressure waveforms; both were visualized on the ultrasound screen. The performance and accuracy of diaphragm excursion and thickening to detect each asynchrony were compared with a "control method" of flow/pressure tracings alone, and a "working standard method" combining flow, airway pressure, and diaphragm electromyography signals analyses. RESULTS: Ultrasound recordings were performed for the 15 volunteers, unlike electromyography recordings which could be collected in only 9 of 15 patients (60%). Autotriggering was correctly identified by continuous recording of electromyography, excursion, thickening, and flow/pressure tracings with sensitivity of 93% (95% CI, 89-97%), 94% (95% CI, 91-98%), 91% (95% CI, 87-96%), and 79% (95% CI, 75-84%), respectively. Delayed cycling was detected by electromyography, excursion, thickening, and flow/pressure tracings with sensitivity of 84% (95% CI, 77-90%), 86% (95% CI, 80-93%), 89% (95% CI, 83-94%), and 67% (95% CI, 61-73%), respectively. CONCLUSIONS: Ultrasound is a simple, bedside adjustable, clinical tool to detect the majority of patient-ventilator asynchronies associated with noninvasive ventilation leaks, provided that it is possible to visualize the airway pressure curve on the ultrasound machine screen. Ultrasound detection of autotriggering and delayed cycling is more accurate than isolated observation of pressure and flow tracings, and more feasible than electromyogram.


Assuntos
Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Ventilação não Invasiva/métodos , Ultrassonografia/métodos , Adulto , Feminino , Humanos , Masculino , Valores de Referência , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
7.
BMC Neurol ; 20(1): 79, 2020 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-32138697

RESUMO

BACKGROUND: The most characteristic clinical signs of stroke are motor and/or sensory involvement of one side of the body. Respiratory involvement has also been described, which could be related to diaphragmatic dysfunction contralateral to the brain injury. Our objective is to establish the incidence of diaphragmatic dysfunction in ischaemic stroke and analyse the relationship between this and the main prognostic markers. METHODS: A prospective study of 60 patients with supratentorial ischaemic stroke in the first 48 h. Demographic and clinical factors were recorded. A diaphragmatic ultrasound was performed for the diagnosis of diaphragmatic dysfunction by means of the thickening fraction, during normal breathing and after forced inspiration. Diaphragmatic dysfunction was considered as a thickening fraction lower than 20%. The appearance of respiratory symptoms, clinical outcomes and mortality were recorded for 6 months. A bivariate and multivariate statistical analysis was designed to relate the incidence of respiratory involvement with the diagnosis of diaphragmatic dysfunction and with the main clinical determinants. RESULTS: An incidence of diaphragmatic dysfunction of 51.7% was observed. 70% (23 cases) of these patients developed symptoms of severe respiratory compromise during follow-up. Independent predictors were diaphragmatic dysfunction in basal respiration (p = 0.026), hemiparesis (p = 0.002) and female sex (p = 0.002). The cut-off point of the thickening fraction with greater sensitivity (75.75%) and specificity (62.9%) was 24% (p = 0.003). CONCLUSIONS: There is a high incidence of diaphragmatic dysfunction in patients with supratentorial ischaemic stroke which can be studied by calculating the thickening fraction on ultrasound. Among these patients we have detected a higher incidence of severe respiratory involvement.


Assuntos
Isquemia Encefálica/complicações , Diafragma/fisiopatologia , Transtornos Respiratórios/epidemiologia , Transtornos Respiratórios/etiologia , Idoso , Diafragma/diagnóstico por imagem , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Transtornos Respiratórios/fisiopatologia , Acidente Vascular Cerebral/complicações , Ultrassonografia
8.
Br J Radiol ; 93(1110): 20190771, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32208971

RESUMO

OBJECTIVES: Computed tomography scans of the kidney, ureters, and bladder (CT-KUB) are crucial in investigating urinary calculi but impart a substantial radiation doses. Radiation can be limited by minimising the scanning field to the necessary area (i.e. from the kidneys to urethra). Before auditing, the superior limit of CT-KUB scans had not been formally clarified at our trust. Consistently ensuring the upper limit of scans is at or below T10 has been shown to be a viable method of performing CT-KUB scans. This study aimed to assess the overscan length of CT-KUB investigations and modify practice accordingly to minimise it. There were two standards that were set for CT-KUB scanning. First, the mean percentage overscan length (i.e. percentage of the scan above the kidneys) should be <15%. Second, all scans should include the superior borders of both kidneys. METHODS: 90 consecutive CT-KUB scans for ureteric calculus were retrospectively investigated using IMPAX software in the first phase of data collection. After these data were analysed, a newly devised protocol using T11 as the superior scan limit was delivered to radiographers in the department. and 105 in the second phase (re-audit). The analysis parameters were: percentage overscan length, distance between diaphragm and upper border of kidneys, vertebral level at which the scan commenced, and whether both kidneys were fully included. RESULTS: In the first phase, overscan of >15% was present in 94.4% of scans. The mean percentage overscan length was 28.2%. The superior vertebral limit of 59% of scans was at T10 or below and a lower superior vertebral limit correlated with decreasing overscan. 99% of scans fully included both kidneys. In the second phase (3 months later), the mean overscan percentage reduced to 10.6% (standard deviation = 4.4%). Excessive overscan affected 35.2% of scans. The superior vertebral limit of 8% of scans was at T10 or below. 100% of scans fully included both kidneys. CONCLUSION: Excessive overscanning was due to inconsistent technique in capturing CT-KUB scans. Before this audit, the superior limit of CT-KUB scans had not been formally clarified at our trust. By successfully standardising the process with a reproducible method, the overscan target was comfortably met. Therefore, patient dose was minimised without compromising scan quality. ADVANCES IN KNOWLEDGE: This audit has successfully shown a feasible standardised protocol for CT-KUB investigations which can be used to minimise overscanning of patients.


Assuntos
Rim/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Ureter/diagnóstico por imagem , Bexiga Urinária/diagnóstico por imagem , Cálculos Urinários/diagnóstico por imagem , Pontos de Referência Anatômicos/diagnóstico por imagem , Diafragma/diagnóstico por imagem , Humanos , Auditoria Médica , Doses de Radiação , Exposição à Radiação/prevenção & controle , Reprodutibilidade dos Testes , Estudos Retrospectivos , Software , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Cálculos Ureterais/diagnóstico por imagem
9.
Crit Care ; 24(1): 85, 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164784

RESUMO

BACKGROUND: Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. METHODS: This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. RESULTS: Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH2O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. CONCLUSION: Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.


Assuntos
Diafragma/diagnóstico por imagem , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/terapia , Ultrassonografia/métodos , Trabalho Respiratório , Estado Terminal , Diafragma/patologia , Diafragma/fisiopatologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Debilidade Muscular/diagnóstico por imagem , Estudos Prospectivos , Insuficiência Respiratória/patologia
10.
Anesthesiology ; 132(5): 1114-1125, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32084029

RESUMO

BACKGROUND: The assessment of diaphragm function with diaphragm ultrasound seems to bring important clinical information to describe diaphragm work and weakness. When the diaphragm is weak, extradiaphragmatic muscles may play an important role, but whether ultrasound can also assess their activity and function is unknown. This study aimed to (1) evaluate the feasibility of measuring the thickening of the parasternal intercostal and investigate the responsiveness of this muscle to assisted ventilation; and (2) evaluate whether a combined evaluation of the parasternal and the diaphragm could predict failure of a spontaneous breathing trial. METHODS: First, an exploratory evaluation of the parasternal in 23 healthy subjects. Second, the responsiveness of parasternal to several pressure support levels were studied in 16 patients. Last, parasternal activity was compared in presence or absence of diaphragm dysfunction (assessed by magnetic stimulation of the phrenic nerves and ultrasound) and in case of success/failure of a spontaneous breathing trial in 54 patients. RESULTS: The parasternal was easily accessible in all patients. The interobserver reproducibility was good (intraclass correlation coefficient, 0.77 (95% CI, 0.53 to 0.89). There was a progressive decrease in parasternal muscle thickening fraction with increasing levels of pressure support (Spearman ρ = -0.61 [95% CI, -0.74 to -0.44]; P < 0.0001) and an inverse correlation between parasternal muscle thickening fraction and the pressure generating capacity of the diaphragm (Spearman ρ = -0.79 [95% CI, -0.87 to -0.66]; P < 0.0001). The parasternal muscle thickening fraction was higher in patients with diaphragm dysfunction: 17% (10 to 25) versus 5% (3 to 8), P < 0.0001. The pressure generating capacity of the diaphragm, the diaphragm thickening fraction and the parasternal thickening fraction similarly predicted failure or the spontaneous breathing trial. CONCLUSIONS: Ultrasound assessment of the parasternal intercostal muscle is feasible in the intensive care unit and provides novel information regarding the respiratory capacity load balance.


Assuntos
Diafragma/diagnóstico por imagem , Músculos Intercostais/diagnóstico por imagem , Respiração Artificial/métodos , Ultrassonografia de Intervenção/métodos , Desmame do Respirador/métodos , Adulto , Diafragma/fisiologia , Feminino , Humanos , Músculos Intercostais/fisiologia , Masculino , Adulto Jovem
11.
JAMA Netw Open ; 3(2): e1921520, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32074293

RESUMO

Importance: Low diaphragm muscle mass at the outset of mechanical ventilation may predispose critically ill patients to poor clinical outcomes. Objective: To determine whether lower baseline diaphragm thickness (Tdi) is associated with delayed liberation from mechanical ventilation and complications of acute respiratory failure (reintubation, tracheostomy, prolonged ventilation >14 days, or death in the hospital). Design, Setting, and Participants: Secondary analysis (July 2018 to June 2019) of a prospective cohort study (data collected May 2013 to January 2016). Participants were 193 critically ill adult patients receiving invasive mechanical ventilation at 3 intensive care units in Toronto, Ontario, Canada. Exposures: Diaphragm thickness was measured by ultrasonography within 36 hours of intubation and then daily. Patients were classified as having low or high diaphragm muscle mass according to the median baseline Tdi. Main Outcomes and Measures: The primary outcome was time to liberation from ventilation accounting for the competing risk of death and adjusting for age, body mass index, severity of illness, sepsis, change in Tdi during ventilation, baseline comorbidity, and study center. Secondary outcomes included in-hospital death and complications of acute respiratory failure. Results: A total of 193 patients were available for analysis; the mean (SD) age was 60 (15) years, 73 (38%) were female, and the median (interquartile range) Sequential Organ Failure Assessment score was 10 (8-13). Median (interquartile range) baseline Tdi was 2.3 (2.0-2.7) mm. In the primary prespecified analysis, baseline Tdi of 2.3 mm or less was associated with delayed liberation from mechanical ventilation (adjusted hazard ratio for liberation, 0.51; 95% CI, 0.36-0.74). Lower baseline Tdi was associated a higher risk of complications of acute respiratory failure (adjusted odds ratio, 1.77; 95% CI, 1.20-2.61 per 0.5-mm decrement) and prolonged weaning (adjusted odds ratio, 2.30; 95% CI, 1.42-3.74). Lower baseline Tdi was also associated with a higher risk of in-hospital death (adjusted odds ratio, 1.47; 95% CI, 1.00-2.16 per 0.5-mm decrement), particularly after discharge from the intensive care unit (adjusted odds ratio, 2.68; 95% CI, 1.35-5.32 per 0.5-mm decrement). Conclusions and Relevance: In this study, low baseline diaphragm muscle mass in critically ill patients was associated with prolonged mechanical ventilation, complications of acute respiratory failure, and an increased risk of death in the hospital.


Assuntos
Estado Terminal/mortalidade , Diafragma/diagnóstico por imagem , Respiração Artificial/mortalidade , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ultrassonografia
12.
Zhonghua Jie He He Hu Xi Za Zhi ; 43(2): 132-135, 2020 Feb 12.
Artigo em Chinês | MEDLINE | ID: mdl-32062883

RESUMO

Objective: To evaluate the condition of the diaphragm in patients with long-term mechanical ventilation using ultrasound technology and to analyze its relationship with ventilation time and muscle atrophy in order to clarify the reasons for diaphragm dysfunction in long-term mechanical ventilation patients. Methods: Patients admitted to the respiratory department at the Chinese PLA General Hospital between June 2018 and April 2019 with mechanical ventilation were included in this study. The enrolled patients were divided into a short-term mechanical ventilation group (7 days ≤ ventilation time<1 month) and a long-term mechanical ventilation group (mechanical ventilation time ≥ 1 month). The diaphragmatic excursion, inspiratory time, contraction rate, E-T index, diaphragm thickness, diaphragm thickness fraction (DTF), and tibialis anterior thickness were compared between the two groups. The correlation between ventilation time and diaphragm thickness was analyzed in all patients. Results: The mean diaphragm thickness and DTF were significantly lower in the long-term mechanical ventilation group than in the short-term mechanical ventilation group [(0.13±0.036) vs (0.17±0.05) cm and (0.22±0.045) vs (0.27±0.075)](all P<0.05). However, there was no significant difference in diaphragmatic excursion, inspiratory time, contraction rate, E-T index or tibialis anterior thickness between the two groups (all P>0.05). There was a significant linear correlation between ventilation time and diaphragm thickness (P<0.01). Tibialis anterior thickness was not significantly correlated with ventilation time (P>0.05). Conclusion: Diaphragm thickness and function were significantly reduced in patients with long-term mechanical ventilation, which was correlated with the duration of ventilation. Nutritional status was not the main factor affecting diaphragm thickness.


Assuntos
Diafragma/diagnóstico por imagem , Diafragma/fisiopatologia , Atrofia Muscular , Respiração Artificial/efeitos adversos , Ultrassonografia/métodos , Diafragma/fisiologia , Humanos , Contração Muscular/fisiologia , Debilidade Muscular/diagnóstico por imagem , Estudos Prospectivos , Respiração , Fatores de Tempo
13.
Can Assoc Radiol J ; 71(2): 231-237, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32062986

RESUMO

PURPOSE: This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). METHOD AND MATERIALS: We used our hospitals' trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. RESULTS: Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system (F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. CONCLUSION: The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Sistema Digestório/diagnóstico por imagem , Sistema Digestório/lesões , Tomografia Computadorizada Multidetectores , Pelve/lesões , Ferimentos Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/cirurgia , Adolescente , Adulto , Idoso , Diafragma/diagnóstico por imagem , Diafragma/lesões , Feminino , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/lesões , Humanos , Escala de Gravidade do Ferimento , Intestinos/diagnóstico por imagem , Intestinos/lesões , Fígado/diagnóstico por imagem , Fígado/lesões , Masculino , Mesentério/diagnóstico por imagem , Mesentério/lesões , Pessoa de Meia-Idade , Pelve/diagnóstico por imagem , Pelve/cirurgia , Período Pré-Operatório , Estudos Retrospectivos , Sensibilidade e Especificidade , Baço/diagnóstico por imagem , Baço/lesões , Ferimentos Penetrantes/cirurgia , Adulto Jovem
14.
Clinics (Sao Paulo) ; 75: e1428, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31939562

RESUMO

The objectives of the study were to identify the factors that limit diaphragmatic mobility and evaluate the therapeutic results of the monitoring methods previously used in patients with chronic obstructive pulmonary disease. The PubMed, Web of Science, Scopus, and LILACS databases were used. A gray literature search was conducted with Google scholar. PRISMA was used, and the bias risk analysis adapted from the Cochrane Handbook for clinical trials and, for other studies, the Downs and Black checklist were used. Twenty-five articles were included in the qualitative synthesis analysis on physiotherapeutic techniques and diaphragmatic mobility. Eight clinical trials indicated satisfactory domains, and on the Downs and Black scale, 17 cohort studies were evaluated to have an acceptable score. Different conditions must be observed; for example, for postoperative assessments the supine position is suggested to be the most appropriate position to verify diaphragm excursion, although it has been shown to be associated with difficulty of restriction and matching in samples. Therefore, we identified the need for contemporary adjustments and strategies that used imaging instruments, preferably in the dorsal position. Therapeutic evidence on the association between the instrumental method and diaphragmatic mobility can be controversial. The ultrasound measurements indicated some relevance for different analyses, for pulmonary hyperinflation as well as diaphragm thickness and mobilization, in COPD patients. In particular, the study suggests that the ultrasound technique with B-mode for analysis and M-mode for diaphragmatic excursion be used with a 2 - 5 MHz with the patient in the supine position. However, the methods used to monitor diaphragm excursion should be adapted to the conditions of the patients, and additional investigations of their characteristics should be performed. More selective inclusion criteria and better matching in the samples are very important. In addition, more narrow age, sex and weight categories are important, especially in patients with chronic obstructive pulmonary disease.


Assuntos
Diafragma/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Diafragma/diagnóstico por imagem , Humanos , Amplitude de Movimento Articular , Ultrassonografia
15.
PLoS One ; 15(1): e0227872, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31978157

RESUMO

This study aimed to examine age-specific reference intervals and growth dynamics of the best fit for liver dimensions on the diaphragmatic surface of the fetal liver. The research material consisted of 69 human fetuses of both sexes (32♂, 37♀) aged 18-30 weeks. Using methods of anatomical dissection, digital image analysis and statistics, a total of 10 measurements and 2 calculations were performed. No statistical significant differences between sexes were found (p>0.05). The parameters studied displayed growth models that followed natural logarithmic functions. The mean value of the transverse-to-vertical diameter ratio of the liver throughout the analyzed period was 0.71±0.11. The isthmic ratio decreased significantly from 0.81±0.12 in the 18-19th week to 0.62±0.06 in the 26-27th week, and then increased to 0.68±0.11 in the 28-30th week of fetal life (p<0.01). The morphometric parameters of the diaphragmatic surface of the liver present age-specific reference data. No sex differences are found. The transverse-to-vertical diameter ratio supports a proportionate growth of the fetal liver. Quantitative anatomy of the growing liver may be of relevance in both the ultrasound monitoring of the fetal development and the early detection of liver anomalies.


Assuntos
Diafragma/crescimento & desenvolvimento , Desenvolvimento Fetal/fisiologia , Fígado/crescimento & desenvolvimento , Pesos e Medidas Corporais , Diafragma/diagnóstico por imagem , Feminino , Feto/diagnóstico por imagem , Idade Gestacional , Humanos , Lactente , Fígado/diagnóstico por imagem , Masculino , Tomografia Computadorizada por Raios X
17.
Ann R Coll Surg Engl ; 102(2): e23-e25, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31508987

RESUMO

Epidermoid cysts are rare lesions that can occur anywhere in the body. They are associated with elevated serum levels of CA 19-9. The spleen represents the most common site of intra-abdominal localisation. Only two cases of diaphragmatic epidermoid cyst are reported in the literature. We present the case of a 61-year-old woman with a small suprasplenic subdiaphragmatic cyst discovered during the investigation of left flank pain. The establishment of an adequate diagnosis was challenging due to the difficulty in specifying the exact localisation of the cyst, the extremely elevated CA 19-9 level of 19,000 and the high uptake on 18-fluoro-2-deoxy-D-glucose positron emission tomography. The definitive diagnosis followed complete surgical excision. Intra-abdominal epidermoid cysts are usually discovered incidentally on imaging for another reason. The cyst is lined by squamous epithelium responsible for the secretion of CA 19-9. The elevation of serum CA 19-9 is due to small rupture or increased intraluminal pressure followed by diffusion to the bloodstream. Surgery with en-bloc resection represents the optimal treatment to avoid any risk of recurrence. The definitive diagnosis is established by demonstrating positive immunohistopathological staining of epithelial cell to CA 19.9.


Assuntos
Antígeno CA-19-9/sangue , Diafragma/diagnóstico por imagem , Cisto Epidérmico/diagnóstico , Biomarcadores/sangue , Diafragma/cirurgia , Cisto Epidérmico/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Tomografia Computadorizada por Raios X
18.
Int J Chron Obstruct Pulmon Dis ; 14: 2479-2484, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31806957

RESUMO

Purpose: Impairment of diaphragmatic function is one of the main pathophysiological mechanisms of chronic obstructive pulmonary disease (COPD) and is known to be related to acute exacerbation. Ultrasonography (US) allows for a simple, non-invasive assessment of diaphragm kinetics. The purpose of this study was to investigate the changes in diaphragmatic function during acute exacerbation of COPD, by US. Methods: This single-center, prospective study included patients with acute exacerbation of COPD symptoms. US measurements were performed within 72 hrs after exacerbation and after improvement of symptoms. Diaphragmatic excursion and its thickening fraction (TF) were measured as markers of diaphragmatic function. TF was calculated as (thickness at end inspiration - thickness at end expiration)/thickness at end expiration. Results: Ten patients were enrolled. All patients were male, and the mean age was 79.8 years. The TF of the right diaphragm showed a significant increase from the initial to the follow-up values (80.1 ± 104.9 mm vs. 159.5 ± 224.6 mm, p = 0.011); however, the diaphragmatic excursion did not vary significantly between the initial and follow-up values (22 ± 6 mm vs 23 ±12 mm). The change in excursion between the stable and exacerbation periods was positively correlated with time to the next exacerbation and negatively correlated with the time taken to recover from the exacerbation. Conclusion: These data support the possibility that a defect in diaphragm thickening is related to acute exacerbation of COPD.


Assuntos
Diafragma/diagnóstico por imagem , Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/diagnóstico por imagem , Ultrassonografia , Idoso , Idoso de 80 Anos ou mais , Diafragma/fisiopatologia , Progressão da Doença , Volume Expiratório Forçado , Humanos , Masculino , Projetos Piloto , Valor Preditivo dos Testes , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Capacidade Vital
19.
Arq. ciências saúde UNIPAR ; 23(3)set-dez. 2019.
Artigo em Português | LILACS | ID: biblio-1046203

RESUMO

A mobilidade diafragmática é essencial para a ventilação pulmonar. Pela ultrassonografia sua mensuração é direta, porém o processamento das medidas encontra-se em divergência na literatura. Indica-se pelo valor médio das três incursões respiratórias máximas ou o maior valor dentre elas restringindo à variações de 10%. Dessa forma, não existe um consenso em relação ao processamento da medida de mobilidade diafragmática máxima. Objetivo: Comparar dois diferentes processamentos das medidas pela ultrassonografia para o maior valor de mobilidade diafragmática. Materiais e métodos: Estudo observacional transversal. Avaliou-se a mobilidade diafragmática pela ultrassonografia, com um transdutor convexo (3 MHz) posicionado anteriormente na região subcostal e leve inclinação cranial, em decúbito dorsal. Visualizou-se o hemidiafragma direito pelo ponto médio entre a linha médio clavicular e axilar anterior. Para visualizar a janela do diafragma e mensurar sua mobilidade foi utilizado o modo B, seguido do modo M. Os participantes realizaram inspirações máximas e os maiores valores com diferença máxima de 10% entre eles mensurados e registrados. Para análise, o maior valor e o valor médio obtido das três medidas foram considerados. Para normalidade dos dados foi realizado o teste de Shapiro Wilk. Para diferenças entre os registros, o teste de t student. Resultados: 30 indivíduos (30,33 ± 9,7 anos), 16 mulheres e 14 homens. A medida da mobilidade diafragmática pelo maior valor em comparação ao valor médio apresentou diferença estatisticamente significante (8,11 ± 1,43 cm versus 7,79 ± 1,43 cm; p<0,001). Conclusão: O valor máximo da mobilidade diafragmática foi obtido por meio da análise do maior valor. Ao escolher a média, a mobilidade diafragmática pode ser subestimada. 


Diaphragmatic mobility is essential to pulmonary ventilation. It can be directly measured by using ultrasonography, but the processing of the measurements can be found described differently in the literature. It can be measured as the average of at least three different cycles or from the greatest value among them resticting it to a 10% variation. Thus, there is no consensus about the processing of the maximum measurement of diaphragmatic mobility. Objective: Comparisson of two differents ultrasound measurement processings aiming at the diaphragmatic mobility maximum value. Methodology: Cross-sectional observational study. The diaphragmatic mobility was assessed by ultrasonography with convex transducer (3MHz) placed on the subcostal region between the midclavicular and anterior axillary. In order to explore the right diaphragmatic window and mobility, the B mode was used, followed by the M mode. The participants made maximum inspiration, and the highest value with a maximum difference of 10% was recorded. For statistical analysis, the mean and the highest value of three measurements were considered. The data distribution was analyzed with a Shapiro Wilk test and differences among records by the t student test. Results: 30 participants (30.33 ± 9.7 years) - 16 women and 14 men. The measurement of the diaphragmatic mobility obtained by the highest value compared against the mean value presented a statistically significant difference (8.11 ± 1.43 cm vs 7.79 ± 1.43 cm; p<0.001). Conclusions: The maximum value of diaphragmatic mobility was obtained by the analysis of the highest value. By choosing to use the mean value, diaphragmatic mobility may be underestimated.


Assuntos
Humanos , Masculino , Feminino , Adulto , Adulto Jovem , Diafragma/fisiologia , Padrões de Referência , Respiração , Diafragma/diagnóstico por imagem , Distribuição Aleatória , Estudos Transversais , Ultrassonografia , Voluntários Saudáveis , Movimentos dos Órgãos
20.
BMJ Case Rep ; 12(11)2019 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-31678925

RESUMO

Pleural effusion in liver cirrhotics is more commonly transudative. A transudative pleural effusion secondary to ascites in decompensated cirrhosis is also known as hepatic hydrothorax and is usually due to fluid seepage through congenital pores in the diaphragm. The patient, a known case of decompensated chronic liver disease, presented with a massive, left-sided, rapidly accumulating and transudative pleural effusion secondary to spontaneous diaphragmatic rupture. Clinically, he developed sudden onset shortness of breath and became hypotensive. This is a rare entity, and was confirmed on CT thorax revealing a focal segment defect ~1.6 cm over the left hemidiaphragm. Ascites treatment consisting of diuretics with salt restriction and repeated thoracentesis with albumin replacement improved his symptoms and lead to a complete resolution of the effusion.


Assuntos
Hidrotórax/etiologia , Cirrose Hepática Alcoólica/complicações , Ruptura Espontânea/complicações , Diafragma/diagnóstico por imagem , Humanos , Hidrotórax/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ruptura Espontânea/diagnóstico por imagem , Ultrassonografia
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